DBA:
Corporate/Legal Name (required)
Full Contact Name
Physical Address
City/State/Zip
Mailing Address
Business Phone/Fax
Your Email
Website URL
Referred By
Ownership Type Sole ProprietorshipPartnershipNon-ProfitPublic CorporationPrivate
Years in Business
Merchant Type (SIC/MCC Code):
Business License #:
Federal Tax ID:
State Tax ID:
Check One: RetailRestaurant with TipsRestaurant without TipsMO/TO
Product/Service Description:
Average Ticket Size:
Monthly Credit Card Volume:
Mag Swipe:
Keyed Manually:
American Express Account: NewExisting
Discover Account: NewExisting
Other Card Account: NewExisting
EBT:
FNS# (XREF):
Check Service:
Deposit CK Account: Routing/Transit#:
Account#:
Changeback CK Account: Routing/Transit#:
Owner/Officer Name:
Date Of Birth:
Home Phone:
City/State/Zip:
Drivers License#/State:
Owner/Officer Name #2:
Gift/Loyalty Card Program: YesNo
Area Zoned: 0-500501-2,5002,501-5,0005,001-10,000Greater Than 10,001
Square Footage: CommercialIndustrialResidential
Building Type: Shopping CenterOffice BuildingResidenceSeparate BuildingOther
Merchant: OwnsRents/Leases
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